1. Covered California enrollment tops 600,000

Covered California, the state’s health benefit exchange, has released new enrollment numbers, which reflect activity during its October through December pre-enrollment period.

As of December 31, 500,108 Californians had officially purchased insurance covered through a plan offered on Covered California’s online marketplace. Of that figure, roughly 85 percent are eligible for some level of government subsidy.

Additionally, when preliminary numbers from the first two weeks of January are added, the total rises to slightly more than 625,000, according to exchange officials.

“We are pleased that Californians – many for the first time – are getting quality, affordable health insurance to protect themselves and their families,” said Peter Lee, the exchange’s executive director.

Many enrollees in Covered California health insurance plans who paid their first month’s premium by January 15 received health care retroactive to January 1, while Anthem Blue Cross and Health Net exchange enrollees will have until January 31 to pay their first month’s premium. Enrollees submitting payments after the first month premium deadlines will get coverage starting February 1. The initial open enrollment period continues through March 31.

In addition to those purchasing coverage through exchange, the state’s Department of Health Care Services also enrolled more than 1.2 million Californians in the state’s expanded Medi-Cal program. Of these enrollees, roughly 630,000 are transitioning directly from an existing Low Income Health Program, while an additional 584,000 are those that were deemed “likely eligible” for Medi-Cal during the Covered California enrollment process.

While exchange officials have touted these figures as a success for the state’s new insurance marketplace, many observers note that enrollment in key demographic groups continues to lag.

Of the roughly 400,000 consumers who responded to questions regarding ethnicity, less than 20 percent identified as Latino. Meanwhile, Latinos make up roughly 46 percent of the population believed to be eligible for subsidized coverage, as well as more than half of the state’s 7 million uninsured residents.

Additionally, nearly half of all those purchasing coverage on the exchange fall in the 45-64 age group, while that group accounts for only 25 percent of the state’s overall population. This has raised concerns among many that the risk mix of the exchange population will be poor, necessitating significant premium rate increases for next year.

California physicians with questions regarding participation in Covered California are encouraged to visit the California Medical Association’s exchange resource center, which includes a guide to navigating the first months of the exchange. The resource center can be found at www.cmanet.org/exchange.

It is critical that physicians and their staff have a clear understanding of their exchange plan participation status so they can communicate this information to patients before scheduling. It’s equally as important that practices understand the reimbursement rates and other terms associated with the plans with which they are contracted.

Even if you did not intentionally contract with any exchange plans, the California Medical Association (CMA) urges physicians to check their participation status. It is very possible that physicians may be unaware they have been opted into an exchange plan network due to the way that major insurance plans have structured their provider agreements.

If you've attempted to look up your exchange plan participation status on the Covered California website, you know that it's not a straightforward process. Because it is critical that physicians know what plans they are contracted with, CMA has created a quick and easy tool to look up your exchange plan participation status in just a few clicks.

The tool, available to members only, requires simply your first and last name and middle initial and it will tell you which plans list you as a contracting physician (based on data from Covered California as of September 2013, the most recent data released by Covered California). To access the tool, visit www.cmanet.org/exchange-lookup.

Furthermore, because the data currently supporting the CMA search tool is from September 2013, practices should verify their participation status with the respective health plans if the participation information seems incorrect or may have changed since September. Covered California is in the process of issuing December 2013 directories and has updated its online search tool for those plans that have submitted December data. CMA will update its search tool soon after those directories are made public.

Please note: You will be required to login with a member account. If you have not already activated your web account, visit www.cmanet.org/activate. If you need assistance activating your account, contact CMA's member service center at (800) 786-4262 or memberservice@cmanet.org.

For more information on Covered California, visit CMA’s exchange resource center at www.cmanet.org/exchange. Physician members and their staff also have free access to CMA’s practice management experts at (888) 401-5911 or economicservices@cmanet.org.

3. Ten Covered California tips for physicians in 2014

California’s health benefit exchange, Covered California, is now in full swing. As of January 14, Covered California reports that 625,564 individuals have enrolled, accounting for nearly a quarter of all exchange enrollments nationwide.

For those unfamiliar, Covered California is not itself an insurer. Rather, it is an online marketplace for health insurance products, where individuals can purchase health insurance products that qualify for the federal premium subsidies. Because Covered California is a marketplace, products offered through it should generally be thought of as commercial health insurance products – as opposed to "public" coverage, like Medi-Cal, where there is a set fee schedule.

Covered California, however, has also taken on the role of active purchaser, meaning that it will behave much like a large employer negotiating coverage terms (e.g., premiums and patient cost-sharing) on behalf of its employees. This, coupled with requirements in federal and state law, has led to a number of important considerations for physicians when contracting with an exchange plan.

Whether your practice is participating or nonparticipating with one or more exchange plans, here are 10 pointers as Covered California takes root in 2014:

1. Verify your participation status and information on Covered California’s central provider directory. Though the directory has improved significantly, the California Medical Association (CMA) continues to find errors in the data. Physicians have reported errors in participation status, board certification, languages spoken, address and specialty. To verify your information in the Covered California directory, follow the directions found in CMA’s physician guide, "Surviving the First Month of Covered California."

2. Review any contracts or contractual amendments for exchange participation. If you are participating in Covered California, it may be helpful to undertake a review of any exchange-specific contract provisions, such as exchange-specific rates and policy manuals that may be incorporated by reference. If questions arise, contact the plan-specific contact listed in "Surviving the First Month of Covered California."

3. Be aware of the off-exchange products that utilize exchange plan networks. Every plan offered in the exchange must also be offered outside of the exchange, using the same network. This has resulted in a number of practices unknowingly seeing patients out-of-network for commercial products that use an exchange network, as these ID cards will not have the Covered California logo on them. For instance, a Blue Shield card may read “individual PPO” in the upper right and list “enhanced PPO” as the product, but only upon further investigation will it show the network as “IFP off exchange,” which is an exchange network.

4. Know who can help patients get more information on exchange plan eligibility and enrollment. For practices getting exchange enrollment questions that they are unprepared to answer, printing out a list of nearby certified enrollment assisters may be helpful. These can be found on the Covered California enrollment assistance website, “Find Help Near You.”

5. Assess your practice’s policies on extending credit to and collections from patients. Some exchange plans will impose high cost-sharing burdens on patients. Furthermore, the currently evolving situation of the first month’s premium due date and delays in enrollee welcome packets may make eligibility verification difficult for some patients. Practices should consider their strategies for protecting themselves against such potential financial risks. Please refer to "CMA's Got You Covered: A physician's guide to Covered California" for more information.

6. Be prepared for exchange patients in grace period coverage limbo. Exchange enrollees receiving subsidies, currently 85 percent of those in Covered California, will be allowed three months of premium delinquency before being terminated for non-payment. If a practice renders services to these patients in the latter two months of the three-month grace period, the plan has the option to suspend payment on those claims and deny them if the patient is terminated for non-payment. California will require exchange plans to represent coverage as inactive for those patients in months two and three of the grace period and give notice to certain physicians of record as to the patient’s status. Practices should have a policy in place for when they encounter patients in this period of uncertain coverage. Please refer to "CMA's Got You Covered: A physician's guide to Covered California" for more information.

7. Know the participation status of physicians, facilities, and other providers that you refer to or use on a regular basis. Covered California plans will require that physicians provide advance notice to patients if they are being referred to an out-of-network provider or an out of network provider is included in their treatment plan. If, however, the provider shows as participating in the plan’s directory, the practice cannot be held liable for the inclusion. Please refer to "CMA's Got You Covered: A physician's guide to Covered California" for more information.

8. Be aware of the patient cost-sharing across exchange plans. Covered California will expect participating plans to encourage physicians to consider patient cost sharing when developing a treatment plan. Furthermore, physicians should consider that high out of pocket costs for things like brand name drugs, imaging and specialty care could impact treatment compliance. More information may be found in the Covered California benefit summaries.

9. Let no envelope from a health insurer go unopened too long. Exchange plans are continually developing critical details as to how these plans will operate, especially in the areas of claims and billing. Many of these details are likely to come via policy manual amendments, which could be in a small envelope or email that is easy to overlook. Stay up to date on such significant changes by subscribing to the CMA Practice Resources (CPR) newsletter.

10. Stay current on significant developments of Covered California that may impact your practice. Stay up to date with exchange developments impacting physicians by subscribing to CMA Alert and CMA Reform Essentials, free newsletters available to both members and nonmembers.. See CMA's newsletter subscription page for more information.

Recognizing the Affordable Care Act’s “grace period” provision to be one of the most confounding provisions of the law, the California Medical Association (CMA) has published an FAQ sheet dedicated entirely to helping physicians make sense of the issue.

Federal law allows Covered California enrollees who receive financial subsidies to keep their health insurance for three months, even if they have stopped paying their premiums. This is known as the “grace period.”

The first month of this grace period will be treated normally, and plans must pay for services rendered. In months two and three, however, the health plan may suspend payment for any services provided to these enrollees – and deny the claims if the enrollee’s coverage is terminated for non-payment of premiums at the end of the third month.

In California, health plans will be required to suspend a subsidized enrollee’s coverage if the enrollee has not paid his or her premiums for more than a month. The health plans also will generally be required to notify the enrollee’s physician that the enrollee has entered month two of the grace period.

5. Covered California grant resources still available to physicians

The CMA Foundation’s outreach efforts are still underway!

Physicians interested in accessing eligibility and enrollment resources made available through Covered California’s provider outreach grant are encouraged to contact their local medical society or the CMA Foundation for more information.